Pulmonary Concepts In Critical Care

Airway Management

AIRWAY MANAGEMENT

1. HUMIDIFICATION – heated cascade
   provides 100% humidification of inhaled gases. Ensure
   systemic hydration is monitored to help keep secretions
   thin.


2. AEROSOL THERAPY – nebulizers
   delivering aerosols increase secretion clearance and
   liquefy mucus; nebulizers may become a source of
   bacterial contamination.


3. CUFF MANAGEMENT – essential for
   prevention of necrosis and aspiration. Two different cuff-inflation
   techniques are currently used:


4. Minimal leak technique (ML) – inject
   air into cuff until no leak is heard and then withdrawing
   the air until a small leak is heard on inspiration. (Problems
   are related to maintaining PEEP, aspiration around the
   cuff, and increased movement of the tube.)


5. Minimal occlusive volume technique (MOV)
   – inject air into cuff until no leak is heard, then
   withdrawing the air until a small leak is heard on
   inspiration, and then adding more air until no leak is
   heard on inspiration. (Problems are related to higher
   cuff pressures than ML technique.) Use only if patient
   needs a seal to provide adequate ventilation and/or is at
   high risk for aspiration.


6. Monitor cuff pressures at least q. 8 h.
   Maintain pressure 18 to 22 mm Hg (25 to 30 cm H2O.
   Greater pressures decrease capillary blood flow in
   tracheal wall and lesser pressures increase risk of
   aspiration. Do not routinely deflate cuff.


7. POSTURAL DRAINAGE & POSITIONING (see
   respiratory references).


8. Key Point: Pneumonia = "Good lung
   down position"


9. ARDS = prone positioning for improved
   oxygenation


10. SUCTIONING – perform as sterile
    procedure only when patient needs it and not on a routine
    schedule. Observe for hypoxemia, atelectasis,
    bronchospasms, cardiac dysrhythmias, hemodynamic
    alterations, increased intracranial pressure, and airway trauma.

ENDOTRACHEAL/ TRACHEAL SUCTIONING PROCEDURE

OBJECTIVES:

The nurse performs endotracheal and tracheostomy suctioning to:

1. Maintain a patent airway.


2. To improve oxygenation and reduce the work of
   breathing.


3. To remove accumulated tracheobronchial secretions
   using sterile technique.


4. Stimulate the cough reflex.


5. Prevent pulmonary aspiration of blood and gastric
   fluids.


6. Prevent infection and atelectasis.

EQUIPMENT:
Sterile normal saline

Suction source

Ambu bag connected to 100% O2

Clear protective goggles/mask or face shield

Sterile gloves for open suction

Clean gloves for (in-line) closed suction

Sterile catheter with intermittent suction control port or In-line
suction catheter

PROCEDURE:

1. Wash hands. Reduces transmission of
microorganisms.

2. Assess patient’s need for
suctioning. Since endotracheal suctioning can be hazardous
and causes discomfort, it is not recommended in the absence
of apparent need.

Coarse breath sounds

Coughing; increased respirations

Increased PIP on ventilator

3. Don goggles and mask or face shield.
Potential for contamination

4. Turn on suction apparatus and set vacuum
regulator to appropriate negative pressure. Recommend 80-120
mmHg; adjust lower for children and the elderly. Significant
hypoxia and damage to tracheal mucosa can result from
excessive negative pressure.

5. Prepares suction apparatus. Secure one
end of connecting tube to suction machine, and place other
end in a convenient location within reach.

6. Use in-line suction catheter or open
sterile package (catheter size not exceeding one-half the
inner diameter of the airway) on a clean surface, using the
inside of the wrapping as a sterile field.

7. Prepares catheter and prevents
transmission of microorganisms. Catheter exceeding one-half
the diameter increases possibility of suction-induced hypoxia
and atelectasis.

8. Prepare catheter flush solution.With in-line
catheter use sterile saline bullets to flush catheter. With
regular suctioning set up sterile solution container and
being careful not to touch the inside of the container, fill
with enough sterile saline or water to flush catheter.

9. With in-line suction catheter use clean
gloves. With regular suctioning, done sterile gloves.
Maintain sterility. Universal precautions. In regular
suctioning the dominant hand must remain sterile throughout
the procedure.

10. Pick up suction catheter, being careful
to avoid touching nonsterile surfaces. With nondominant hand,
pick up connecting tubing. Secure suction catheter to
connecting tubing. Maintains catheter sterility. Connects
suction catheter and connecting tubing

11. Ensures equipment function. Check
equipment for proper functioning by suctioning a small amount
of sterile saline from the container. (skip this step in in-line
suctioning)

12. Remove or open oxygen or humidity
device to the patient with nondominant hand. (skip this step
with in-line suctioning). Opens artificial airway for
catheter entrance. Have second person assist when indicated
to avoid unintentional extubation.

13. Replace O2 delivery device or reconnect
patient to the ventilator. Hyperoxygenate and hyperventilate
via 3 breaths by giving patient additional manual breaths on
the ventilator before suctioning. Hyperoxygenation with 100%
O2 is used to offset hypoxemia during interrupted oxygenation
and ventilation. Preoxygenation offsets volume and O2 loss
with suctioning. Patients with PEEP should be suctioned
through an adapter on the closed suction system.

14. Without applying suction, gently but
quickly insert catheter with dominant hand during inspiration
until resistance is met; then pull back 1-2 cm. Catheter is
now in tracheobronchial tree. Application of suction pressure
upon insertion increases hypoxia and results in damage to the
tracheal mucosa.

15. Apply intermittent suction by placing
and releasing dominant thumb over the control vent of the
catheter. Rotate the catheter between the dominant thumb and
forefinger as you slowly withdraw the catheter. With in-line
suction, apply continuous suction by depressing suction valve
and pull catheter straight back. Time should not exceed 10-15
seconds. Intermittent suction and catheter rotation prevent
tracheal mucosa when using regular suctioning methods. Unable
to rotate with closed- suction method.

16. Replace oxygen delivery device.
Hyperoxygenate between passes of catheter and following
suctioning procedure. Replenishes O2. Recovery to base PaO2
takes 1 to 5 minutes. Reduces incidence of hypoxemia and
atelectasis.

17. Rinse catheter and connecting tubing
with normal saline until clear. Removes catheter secretions.

18. Monitor patient’s cardiopulmonary
status during and between suction passes. Observe for signs
of hypoxemia, e.g. dysrhythmias, cyanosis, anxiety,
bronchospasms, and changes in mental status.

19. Once the lower airway has been
adequately cleared of secretions, perform nasal and oral
pharyngeal or upper airway suctioning. Removes upper airway
secretions. The catheter is contaminated after nasal and oral
pharyngeal suctioning and should not be reinserted into the
endotracheal or tracheostomy tube.

20. Upon completion of upper airway
suctioning, wrap catheter around dominant hand. Pull glove
off inside out. Catheter will remain in glove. Pull off other
glove in same fashion and discard. Turn off suction device.
Reduces transmission of microorganisms.

21. Reposition patient. Supports
ventilatory effort; promotes comfort; communicates caring
attitude.

22. Reassess patient’s respiratory
status. Indicates patient’s response to suctioning

23. Dispose of suction liners and
connecting tubing, sterile saline solution every 24 hours and
set up new system. Decreases incidence of organism
colonization and subsequent pulmonary contamination.
Universal precautions.

PRECAUTIONS:

1. Minimize suctioned-induced atelectasis and hypoxemia:

a. Avoid using catheters larger than one-half the
diameter of the airway.

b. Administer one or more postsuctioning
hyperinflations, using manual or sigh breaths on the
ventilator or ambu bag if not ventilated.

2. Maintain rigorous sterile technique when suctioning the
intubated patient. Impaired pulmonary defense systems and
invasive instrumentation of the pulmonary tract predisposes
these patients to colonization and infection. Never use same
catheter to suction the trachea after it has been used in the
nose or the mouth.

3. Limit the frequency of suctioning and avoid, as much as
possible, catheter impaction in the bronchial tree when the
patient is anticoagulated or when hemorrhage from suction-induced
trauma is evident.

4. Minimize the frequency and duration of suctioning when
patient is on positive end-expiratory pressure (PEEP) greater
than 5 cm or continuous positive airway pressure (CPAP).
Small suctioning-induced changes may have profound effects on
these marginally oxygenated patients.

5. Maintain awareness of the limitations of ET/tracheal
suctioning. Maneuvers and catheter design have been proposed
to increase the likelihood of passage into the left bronchus;
however, these have been shown to be of limited success.
Because the left main stem bronchus emerges from the trachea
at the 45-degree angle from the vertical, suction catheters
are almost inevitable passed into the right bronchus (when
they pass the carina) despite head-turning, etc.

6. The use of saline installations for loosening
secretions has been controversial and recent research shows
that in fact it is detrimental and poses a greater risk of
pneumonia for the patient.

RELATED CARE:

1. Include strategies to move secretions through
peripheral airways. These measures are: appropriate hydration
and adequate humidification of inspired gases (to keep
secretions thin); coughing and deep breathing; frequent
position changes (may need rotation bed); chest
physiotherapy; and bronchodilating agents as ordered.

2. Monitor the patient carefully during ET/tracheal
suctioning for ectopic dysrhythmias aggravated by suction-induced
hypoxemia and other dysrhythmias, particularly conduction
disturbances, related to catheter irritation of vagal
receptors within the respiratory tract (requires immediate
cessation of suctioning and hyperoxygenation).

POTENTIAL COMPLICATIONS

Hypoxemia

Atelectasis

Dysrhythmias

Nosocomial pulmonary tract infection

Sepsis

Mucosal trauma with increase secretions

Cardiac arrest